Individuals in our community living with severe illnesses often rely on our services after they go home from hospital. How we manage and support their recovery during this time may reduce the number of unplanned hospital presentations and improve suboptimal patient‐reported outcomes (PROMS).

Rebecca Pang, clinical outreach pharmacist at Peninsula Health. Ms Pang works within the Community Care at Peninsula Health, and is a contributor to the Hospital Admission Risk Program (HARP). The program provides multidisciplinary care navigation to patients in the community, with the view of preventing unwarranted hospital admissions. Pang found that while the HARP care navigation model is of interest, there is conflicting evidence in the literature of its effectiveness and a systematic review of the effectiveness of community care navigation was needed.

Her PhD is focussed on evaluating whether or not a recent trial of a community care navigation model, supported by a hospital readmission risk algorithm, reduced hospital readmissions.

Peninsula Health’s involvement in a Victorian Government Department of Health pilot project, using a hospital readmission risk algorithm and community care navigation model, provided Pang with the opportunity to conduct this body of work while being supported by the Research and Academic unit.

“The Research and Academic unit gave me this opportunity to start my PhD and complete this work to demonstrate how the targeted care navigation approach in HARP effectively reduced hospital readmissions through a robust research methodology,” Ms Pang said.

Using a Cochrane systematic review, the research paper, appropriately titled ‘Community care navigation intervention for people who are at-risk of unplanned hospital presentations’, evaluates the effects of care navigation delivered in the community, on hospital presentations and Patient Reported Outcomes Measures in those at-risk of unplanned hospital presentation. It also aims to assess whether the effects of care navigation on the proposed outcomes differ according to the type of clinician delivering the intervention and the population group receiving the care navigation intervention.

Ms Pang hopes the systematic review will collect global evidence and highlight how this model of care impacts hospital readmission rates. The evidence provided in her paper will guide health system decision-making to improve health outcomes.

To read the full paper, click here.